Intensive Care Nursing: Navigating the Critical Care Environment, Exams of Nursing

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NR 341 Critical Care Nursing - - deals with human responses to critical illness - focus on both the patient's and family's responses Evolution of Critical Care - - began with polio units, recovery rooms, and coronary care units - patient outcomes have improved eICU - a new application of critical care from a remote monitoring site Competencies for Acute and Critical Care Nurses - - clinical reasoning - advocacy - caring - collaboration - holistic nursing care - response to diversity American Association of Critical Care Nurses - - largest specialty organization - assists NURSES to attain knowledge and influence - healthy work environment initiative AACN's Vision - create a healthcare system driven by patient's and family's needs in which critical care nurses make their optimum contributions AACN: Professional Journals - - Critical Care Nurse - American Journal of Critical Care - AACN Advanced Critical Care AACN Membership Benefits - - professional journals - evidence-based interventions - continuing education Society of Critical Care Medicine - - multiprofessional membership - healthcare system in which all critically ill and injured persons receive care Synergy Model - nurses are assigned patients based on their acuity and level of experience of critical care nurses on duty Critical Care Certification - - validate knowledge - promote professional excellence - help nurses maintain up to date knowledge - AACN oversees this CCRN - adult, neonatal and pediatric intensive care PCCN - for those working in step-down units CCNS - Critical Care Clinical Nurse Specialist (Advanced Practice) - greater risk for negative outcomes Calgary Family Assessment - - structural (decision maker) - developmental (stage) - functional (how they interact) EPICS Approach: Addressing Family Needs - - Evaluate - Plan - Involve - Communicate - Support VALUE: Addressing Family Needs - - Value what they tell you - Acknowledge emotions - Listen to family - Understand the patient as a person - Elicit questions form family members Family Present During Codes - allows them to witness everything that has been done Ethical Decision Making Process - - assess - consider options - develop plan with patient - act on plan - evaluate plan Advocacy - - open communication of patient's wishes and ethical concerns - true collaboration with healthcare team members Formal Mechanisms: Joint Commission - - bioethics committee - ethics consultation Preventing Abandonment - - severing professional relationship when patient - ensure that patient care is arranged with another nurse during breaks Elements of Informed Consent - - Competence - Voluntariness - Disclosure of Information Life Sustaining Treatment: Factors to Consider - - constitutional rights - quality of life - impact of advanced technology - ordinary for extraordinary care Ordinary Care - - common, noninvasive, and tested treatment - nutrition, hydration and antibiotics Extraordinary Care - - complex, invasive, experimental treatments - ACLS, dialysis, unproved therapies What is in between ordinary and extraordinary care? - feeding tube for hydration CPR Issues - - DNR is needed to not initiate a code - advance directives are useful - family presence during codes is promoted Withholding - not initiating Withdrawal - weaning or removing Helping Families make Decisions - - communicate frequently - engage in consistent, honest communication - base decisions on patient's wishes - provide support Self Determination Act - - right to initiate advance directive - right to consent or refuse treatment Advance Directive - - communication about preference for treatments if patient is incapacitated - living will (treatment desired and withheld) - durable power of attorney for health care Organ and Tissue Transplantation - - brain dead are often candidates - delirium monitoring - early mobility Fetanyl - fastest onset Morphine - longest duration Epidural - - opioid or local anesthetic - facilitates mobility and pulmonary hygiene NSAIDS - - decrease need for opioid - risks of GI bleeding and renal (ibuprofen) or liver (acetaminophen) insufficiency Pharmacological Treatment for Anxiety - - benzodiazepine - propofol - dexmedetomidine Ventilation - movement of O2 and CO2 in and out of the alveoli Oropharyngeal Sizing - - hold airway against side of patients face - extend from the corner of the patient's mouth to the angle of the jaw Oropharyngeal - - keeps tongue from falling back and blocking the upper airway - used in unresponsive patients with no gag reflex Oropharyngeal Airway Insertion - - open mouth - insert with tip pointing up to avoid pushing tongue back - once tip reaches soft palate, rotate 180 degrees - top should rest on patient's lips Nasopharyngeal Airways - - curved, flexile rubber or plastic tubes inserted into nostril - used on responsive patients - relieves upper airway obstruction and facilitates passage of suction catheter Nasopharyngeal Airway Insertion - - lubricate and insert into nostril that appears most open - insert until the flange is against the nostril opening - check to ensure airflow - good if they need to be suctioned frequently Suctioning - - suction intermittenly (10-15 sec) - suction only as far into the mouth as you can see and only when catheter is withdrawn - suction only as far into the nose as the distance from the tip of the nose to the earlobe - pre oxygenate before suctioning Hypoxemic Respiratory Failure Type 1 - - when you don't have enough oxygen in your blood but your levels of carbon dioxide are close to normal - PaO2 <60 mmHg - PaCO2 normal Hypercapnic Respiratory Failure Type 2 - - when there's too much CO2 in your blood and near normal or not enough oxygen - PaCO2 >50 mmHg - < 7.3 Indications for Mechanical Ventilation - - airway compromise - respiratory failure - need to protect the airway Acute Respiratory Failure - - Ventilation/Perfusion (V/Q) mismatch - results when lungs cannot adequately oxygenate or eliminate CO2 Acute Respiratory Failure Interventions - - treat the underlying cause - support - ensure comfort, pain control and psychological support Acute Respiratory Distress Syndrome - - direct or indirect injury - death can occur in 48 hours Oscillatory Ventilation - - Delivers low tidal volume at fast rate (300-429 bpm) - used in patients with noncompliant lungs (ARDS) - close monitoring - sedation and paralysis indicated ARDS Interventions - - sedation and comfort - allows patient to generate spontaneous breaths - detects patient breaths and doesn't initiate ventilatory breath - weaning Positive End Expiratory Pressure (PEEP) - - amount of pressure remaining in the lung at the end of expiratory phase - 5-20 Continuous Positive Airway Pressure - - a preset pressure is present in the circuit and lungs throughout both inspiratory and expiratory phases - keeps alveoli from collapsing - patient must be spontaneously breathing - used in conjunction with weaning Anxious Patient: Ventilation - - malfunction of ventilator - patient may need to be suctioned - frequently the patient needs medication Low Pressure Alarm - - attempt to quickly find the problem - usually due to a leak in the circuit - bag the patient High Pressure Volume - - blockage in the circuit - patient biting ETT - mucus plug - patient coughing - bag patient Low Minute Volume Alarm - - apnea (CPAP) - disconnection of the patient from the ventilator - bag patient Accidental Extubation - - ensure ambu bag is attached to oxygen and it is on - attach face mask to ambu bag - ensure good seal - supply patient with ventilation Norcuron (Cecuronium Bromide) - neuromuscular blocking agent Dexamethasone - corticosteroid that prevents the release of substance in the body that cause inflammation Ipratropium - relaxes muscles around the airways so that they open up and you can breath easily Rapid Response - - failure to recognize causes death - implemented to address changes in condition before cardiac or respiratory arrest When to call RRT? - changes in - heart rate, systolic BP - RR, oxygen saturation - mental status - urinary output - lab values Code Blue - - cardiac or respiratory arrest - lifesaving resuscitation and intervention needed Sequence of Events: BLS - - advance directives - airway open - breathing (O2) - chest compressions ACLS: Airway and Breathing - - airway management - manual ventilation - intubation - delivery of tidal volume Bag Valve Mask - - connected to an oxygen source set at 15L/min - ever 5-6 seconds ACLS: Circulation - - large bore IV's - biggest veins - may insert central line - intraosseous if IV access is difficult Normal pH - 7.35-7.45 Second Nurse - - coordinates crash cart - prepares meds - assembles equipment Nursing Supervisor - - controls crowd - contacts attending physician - assists with meds and procedures - ensures a bed is available it critical care - assists with transfer Nurse or Assistant - records events Role of Nurse During Intubation - - makes sure RSI available - inform patient what is going on - preoxygenate patient Reversible Causes of Cardiac Arrest: H - - hypovolemia (decreased amount of circulating blood) - hypoxia - hydrogen ion (acidosis) - hypo/hyperkalemia - hypothermia Reversible Causes of Cardiac Arrest: T - - tension pneumothorax - tamponade (fluid collecting in sac around heart) - toxins - thrombosis Epinephrine - - vasoconstrictor - increases everything - indicated for the restoration of cardiac electrical activity - given every 3-5 min, 1 mg Atropine - - increase heart rate by decreasing vagal tone - indicated for patients with symptomatic bradycardia Vasopressin - intense vasoconstriction may be as effective as epi Dopamine - - used for symptomatic hypotension in the absence of hypovolemia - second line medication for symptomatic bradycardia after atropine - used to increase BP Causes of ARF - - hypoventilation - intrapulmonary shunting - ventilation-perfusion mismatching - diffusion defects